In a talk I recently gave at the University of Pennsylvania School of Medicine, I was asked to discuss the challenges and opportunities that I faced during a career as a physician who is also gay. These issues came alive for me as I was writing my talk when I found a letter I wrote to my father years ago:
Dear Dad,
You are about to be 75 and I am almost 40! It’s fair to say we’ve come a long way together.
I wanted to write you on your birthday to let you know how much you mean to me, and how much I respect you for the many good values you passed on to me. I know that I could not have made many of the career choices I have, had you not been the model of a dedicated health care provider who placed the needs of your patients above all else. I think about this a lot, and could go on, but I know both of us would be in tears.
I also want to say how much I appreciate all you have done for me, worried for me, and thought about what was best for me at different times. I want you to know that I am very happy in my life now, and I have to thank you a lot for that.
Happy Birthday.
Love, Harvey
The first part of the letter addressed my decision to start my HIV practice in the 1980s. The second part is more of a shorthand, in which I tried to say, before I came out, that, ‘I know you know’ and all is okay.
The important lesson for most of us is that as we mature, personal and professional issues get intertwined. Ultimately, knowing yourself, feeling comfortable with who you are, and being out about it is critical to accomplishing your goals.
I went to medical school after a detour to law school because I wanted to care for people, not argue their cases. This is why role my father modelled was so important. I decided before I started school that being a real doctor, and doing primary care of some type was to be a guiding principle for me. As a student who grew up in the sixties, a commitment to social justice was also important to me and paradoxically led me to find my own peace as well as my own voice.
I did my training and joined the faculty at what was then Beth Israel Hospital in 1980—just before the dawn of the AIDS epidemic. I had not yet come out, and was fearful of doing so, beyond anything I can explain. Yet as I found myself avoiding getting involved in efforts to care for people with AIDS, I began to realize ways that my avoidance was gnawing at me. This did not feel good, and I knew I had to change from within. For me it meant I had a lot of personal work to do to get myself to the point where I could engage in these issues, but the time and effort was well worth it. There were a few bumps along the road to coming out, but generally I was fortunate to meet with great acceptance from colleagues and friends.
After a short time, I began seeing people with AIDS in my practice, and thinking about what we could do to improve care. A group of us ended up starting the first HIV program integrated into a hospital-based primary care practice in the country. A practice which I am pleased continues in general medicine at Beth Israel Deaconess Medical Center to this day. Change was hard work, both personally and professionally, but how rewarding it was to find a group of like-minded colleagues to work with to create change and end up with a new model of care. From there it was an easy step to realize that HIV was only one of many issues that had a significant impact of LGBT people. Focusing on improving care for all came next.
LGBT people remain largely invisible in health care. If someone asked us to measure the quality of preventive care―basic things like PAP smears and mammography―that we provide to lesbians and bisexual women, we would have no large data bases to evaluate how we do, only small convenience samples. These small samples demonstrate that despite the fact that routine screening should be done according to standards for the general population, lesbians and bisexual women receive basic preventive care four to 10 times less often than they should. It is not clear whether this is because of avoidance of care related to prior experiences, lack of access to care due to difficulty obtaining health insurance or inability to pay, or lack of clear practice guidelines which set standards of practice for care of LGBT people. But it is clear that as few health care providers collect LGBT population based data, it is not possible to measure the quality of preventive care for LGBT people. This one example makes a compelling case for more research and education in order to assure quality care.
It is also vital that we create affirming and inclusive environments for caring for all including LGBT people. One part of that must be creating environments in which care providers are able to be their authentic selves at work. The tasks required to do this are simple but require both a vision that prizes diversity and the leadership to effect change.
We live in both a wonderful time and a challenging time, but change will happen, and each and every one of us have an important role to play in what will happen not just for LGBT people, but for all people. One part of that process, unquestionably, involves coming to terms with who we are and being out about it in both our personal and professional lives.
Harvey Makadon is Director of the National LGBT Health Education Center at The Fenway Institute. He is also Clinical Professor of Medicine at Harvard Medical School, the LGBT Advisor in Harvard Medical School’s Office for Recruitment and Multicultural Affairs, and a member of the Division of General Medicine at Beth Israel Deaconess Medical Center in Boston.
